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Major changes are being implemented in Medicaid’s community-based long term care program.

One of the most dramatic of these changes is the mandatory enrollment of individuals who are eligible for both Medicare and Medicaid in a managed long-term care (MLTC) plan. Dually eligible individuals had previously been exempt from mandatory enrollment.

This new model requires individuals who are expected to need more than 120 days of home care to enroll in an MLTC plan that administers and oversees the home care being provided.

Until recently, the assessment, implementation and oversight of Medicaid long-term home care benefits in New York City was handled by CASA (the home care department within the NYC Human Resources Department) and by the local Departments of Social Services (DSS) in all other counties.

Now, oversight and implementation of home care services is shifting from the Medicaid agencies to MLTC plans. The phasing in of mandatory enrollment in an MLTC plan started in New York City, and is being extended to the other counties around New York State.

Under the previous model, an individual applying for home care services in New York City would submit an application to the CASA office in his or her county. Once the applicant was determined to be financially eligible for Medicaid benefits, the agency would deploy a nurse to assess the applicant. The nurse-assessor would determine how many hours of home care should be provided by Medicaid based on the applicant’s needs, and a home care agency would be assigned to provide the care.

However, the CASA offices are no longer accepting home care applications (with limited exceptions including individuals on hospice and Medicaid waiver programs). A New York City applicant must now apply for community Medicaid and, once approved, must enroll in an MLTC plan. The MLTC plan will conduct the assessment for home care hours and will oversee the implementation of the care.

The previous model was a fee-for-service model, which means that the home care agency providing the services billed Medicaid for the number of hours provided, and in turn, Medicaid would pay the agency a set hourly rate for such care. The new model is based on “capitation,” which means that Medicaid pays the MLTC plan a set dollar amount for every person enrolled in the plan. The amount that Medicaid pays the MLTC plan is not dependent on how many hours of care are provided, which means, for example, that Medicaid pays the MLTC plan the same amount for an individual who receives 4 hours of home care per day as an individual who receives 12 hours per day.

Individuals who are currently receiving Medicaid home care services have been, or will be, sent letters notifying them of mandatory enrollment in an MLTC plan and will have to choose an appropriate plan. Individuals who are now applying for Medicaid will also have to choose an MLTC plan to provide services. If an MLTC plan is not chosen, one will be assigned.

Choosing an MLTC plan can be confusing, as there are three broad types of plans that are available. The MLTC Medicaid Plans manage only long-term home care services (and not regular Medicaid or Medicare benefits). The Medicaid Advantage Plus Plans manage all services from Medicare and Medicaid, and the providers must be “in network.” There is also a plan called PACE, which is for people 55 years and older. The PACE plan arranges all appointments, and manages and coordinates all Medicare and Medicaid services, all of which must be rendered by providers in the PACE program’s network.

The MLTC Medicaid Plans will generally be the best choice, since participants can continue to see their regular doctors and specialists without concern that they are out of network.

Once participants decide which type of plan is preferable, participants will then have to choose one of several MLTC plans in which to enroll. It can easily be seen that the “capitation” model gives the MLTC plans a financial incentive to hold down costs. Since Medicaid pays them an equal amount per person in the plan, regardless of the number of hours of care provided, there are financial pressures to provide fewer hours. We are already seeing statistics that seem to indicate that some MLTC plans are being more generous with home care hours than other MLTC plans.

If you need assistance with applying for Medicaid, or dealing with the various issues involved in the MLTC program, please feel free to contact the Elder Law attorneys at Lamson & Cutner, P.C.

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